What are the treatment options for otitis media?

Treatment of Otitis Media

First-Line Antibiotic Selection

Amoxicillin at high-dose (80-90 mg/kg/day divided into 2 doses) is the definitive first-line antibiotic for acute otitis media in children and adults. 1

• This recommendation is based on amoxicillin's effectiveness against common pathogens (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis), excellent safety profile, low cost, acceptable taste, and narrow microbiologic spectrum 1
• The WHO Expert Committee similarly endorses amoxicillin as the Access-category first choice for acute otitis media 2

When to Use Amoxicillin-Clavulanate Instead

Switch to amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses) as first-line if: 1

• Patient received amoxicillin in the previous 30 days
• Concurrent purulent conjunctivitis is present
• Coverage for beta-lactamase-producing organisms (H. influenzae, M. catarrhalis) is needed 1

The clavulanate component overcomes bacterial resistance mechanisms that cause treatment failures 3

Observation Without Immediate Antibiotics (Watchful Waiting)

Observation is appropriate for children ≥6 months with non-severe AOM who have reliable follow-up mechanisms. 1

Specific Criteria for Observation:

• Children 6-23 months: non-severe unilateral AOM only 1
• Children ≥24 months: non-severe AOM (unilateral or bilateral) 1
• Never for children <6 months (always treat immediately) 1
• Never for severe symptoms (moderate-to-severe otalgia OR fever ≥39°C/102.2°F) 1
• Never for bilateral AOM in children 6-23 months 1

Implementation Requirements:

• Mechanism to ensure follow-up within 48-72 hours must exist 1
• Parents must understand antibiotics may be needed if symptoms persist or worsen 1
• Initiate antibiotics immediately if child worsens or fails to improve within 48-72 hours 1
• Evidence shows watchful waiting reduces antibiotic use by 57% without worsening recovery 4, 5

Treatment Duration by Age

Duration varies by age and severity: 1

• Children <2 years: 10 days (regardless of severity) 1
• Children 2-5 years with mild-moderate symptoms: 7 days 1, 6
• Children ≥6 years with mild-moderate symptoms: 5-7 days 1

Penicillin-Allergic Patients

For non-severe penicillin allergy, use second or third-generation cephalosporins: 1

• Cefdinir: 14 mg/kg/day in 1-2 doses 1
• Cefuroxime: 30 mg/kg/day in 2 doses 1
• Cefpodoxime: 10 mg/kg/day in 2 doses 1
• Ceftriaxone: 50 mg IM or IV per day for 1-3 days 1

Cross-reactivity between penicillins and second/third-generation cephalosporins is lower than historically reported, making these generally safe options 1

Treatment Failure Management

If symptoms worsen or fail to improve within 48-72 hours, reassess and escalate therapy: 1

Second-Line Options:

1. Amoxicillin-clavulanate (if amoxicillin was first-line) 1, 3
2. Intramuscular ceftriaxone 50 mg/kg/day for 1-3 days (if amoxicillin-clavulanate fails) 1, 3
   • A 3-day course is superior to 1-day regimen 1

Third-Line Options:

• Fluoroquinolones (levofloxacin or moxifloxacin) for persistent failures, though not FDA-approved for pediatric otitis media 3
• Tympanocentesis with culture and susceptibility testing after multiple antibiotic failures 1, 3

Pain Management (Critical Priority)

Pain control must be addressed immediately in every patient, regardless of antibiotic decision. 1

• Acetaminophen or ibuprofen should be initiated within the first 24 hours 1
• Continue analgesics throughout the acute phase as needed 1
• Pain relief often occurs before antibiotics provide benefit, as antibiotics do not provide symptomatic relief in the first 24 hours 1
• Even after 3-7 days of antibiotics, 30% of children <2 years may have persistent pain or fever 1

Post-Treatment Follow-Up Expectations

Middle ear effusion commonly persists after successful treatment and does NOT require antibiotics: 1

• 60-70% have effusion at 2 weeks 1
• 40% at 1 month 1
• 10-25% at 3 months 1

This post-AOM effusion (otitis media with effusion) requires monitoring but NOT antibiotics unless it persists >3 months with hearing loss, bilateral disease with documented hearing difficulty, or structural abnormalities develop 1, 7

Otitis Media with Effusion (OME) - No Acute Symptoms

Watchful waiting for 3 months is the standard approach for OME, as 75-90% resolve spontaneously. 7

What NOT to Do:

• Do not use antibiotics for OME (no long-term efficacy, causes harm through resistance and adverse effects) 7
• Do not use antihistamines or decongestants (ineffective) 7
• Do not use corticosteroids (no benefit versus placebo, risk of behavioral changes, adrenal suppression) 7

When to Refer for Tympanostomy Tubes:

• Bilateral persistent disease >3 months with documented hearing loss 1, 7
• Significant impact on child's well-being 7
• Evidence of anatomic damage or language delay 7, 8

Recurrent AOM (≥3 episodes in 6 months OR ≥4 episodes in 12 months)

Prevention strategies are preferred over prophylactic antibiotics: 1

• Pneumococcal conjugate vaccine (PCV-13) 1
• Annual influenza vaccination 1
• Encourage breastfeeding for ≥6 months 1
• Reduce/eliminate pacifier use after 6 months 1
• Avoid supine bottle feeding 1
• Eliminate tobacco smoke exposure 1
• Do not use long-term prophylactic antibiotics 1

Consider tympanostomy tube placement for recurrent AOM (failure rates: 21% for tubes alone, 16% for tubes with adenoidectomy) 1

Critical Pitfalls to Avoid

• Do not use topical antibiotics for acute otitis media (only indicated for otitis externa or tube otorrhea) 1
• Do not use ototoxic preparations (aminoglycosides) when tympanic membrane integrity is uncertain 1
• Do not continue topical therapy alone beyond 72 hours without improvement in perforated cases 3
• Do not misdiagnose OME as AOM - OME has middle ear effusion WITHOUT acute symptoms and does not require antibiotics 1, 7
• Antibiotics do not eliminate risk of complications like mastoiditis (33-81% of mastoiditis patients had received prior antibiotics) 1

Tympanostomy Tube Otorrhea

For acute tube otorrhea, use topical antibiotics (ciprofloxacin-dexamethasone), NOT oral antibiotics. 1